Do most people who have nipple reconstruction have breast reconstruction? Not necessarily. Do you think about nipple reconstruction if you’ve had breast cancer and are in a consultation for breast reconstruction? We are going to answer these questions and others on this episode of the DiepCJourney Podcast about nipple reconstruction at PRMA with my guest, Dr. Courtney Carpenter of PRMA in San Antonio, Texas.
Meet Dr. Carpenter who Performs Nipple Reconstruction
Dr. Carpenter joined PRMA in 2014 after moving her practice and family from Minnesota. She has over eight years’ experience in microsurgery, including head and neck reconstruction, facial trauma, juvenile breast deformities and craniofacial surgery.
Dr. Carpenter is passionate about utilizing her extensive expertise and experience to help transform lives through reconstructive plastic surgery. I want to point out that PRMA uses the co-surgeon model in breast reconstruction, meaning there are two board-certified microsurgeons with the patient in the OR at the time of autologous breast reconstruction surgery. PRMA is part of the IFAR (Institute for Advanced Reconstruction) network of surgeons.
Who Is a Candidate for Nipple Reconstruction?
Dr. Carpenter tells us that for nipple reconstruction most patients are candidates. She explains it is easier to whittle down who is not a candidate. The patients who are not candidates for nipple reconstruction are those who have implant-based reconstruction and have a very thin layer between the skin and the implant.
Even in implant-based reconstruction that is above the muscle, if the patient has skin and a thicker layer of subcutaneous tissue, a nipple reconstruction can be performed in most cases. She emphasizes it is more uncommon to NOT be a candidate for nipple reconstruction.
What Time During the Reconstruction Process is Nipple Reconstruction Done?
Dr. Carpenter tells us it is more surgeon-dependent but on average, it tends to be the very last step that people do.
“That’s why I like nipple reconstruction because it’s the cherry on top of the sundae, the very last step and people are usually very excited to be taking their last step on this journey with breast cancer.”
She gets very excited for people who are having nipple reconstruction. They are finishing this chapter in their life and moving on.
Dr. Carpenter points out it can be combined with a revision. It just depends on what the patient needs for revision, where their scar lines are, or whether they think they might have another touch up. It can be a simple last step in the office if everything else is done. It’s not too complex. It doesn’t involve a lot of pain. The recovery time is very minimal.
How Important is Taking a Photo of the Breast Prior to Mastectomy?
Since I had a skin sparing/nipple sparing double mastectomy and then delayed DIEP flap, I did not need nipple reconstruction. However, I do ask Dr. Carpenter for patients needing nipple reconstruction if she recommends they take a photo of their original nipple/areola complex to recreate the new reconstructed nipples as close to possible as the original nipples?
Dr. Carpenter says she has never outright recommended that patients take photos before their mastectomy. The reason is because at PRMA they take photos at the office, so they always have a record available if that is something patients want to look at.
She feels a photo before a mastectomy might be more suitable for when patients get the tattoo portion of the areola after nipple reconstruction. It can help match a typical color to a skin tone which involves the patient in choosing what color they want. Dr. Carpenter did agree it could be of benefit for patients to take their own photo prior to surgery.
What is the Process of Nipple Reconstruction?
Dr. Carpenter reiterates, that “like most things in plastic surgery, it is surgeon dependent.” She tells us there are a wide variety of ways. One of the less commons ways is building around a construct, like AlloDerm, and wrapping skin around it. There are also methods of surgeons using cartilage. These methods are not as common.
The most common way of nipple reconstruction is taking the tissue using some well know patterns. The skin is cut in one of these patterns, flipping it around and sewing it together creating a nipple just from the surrounding skin. The skate flap and the C-V flap are two of the most common ones used. Dr. Carpenter says she uses the C-V flap and a lot of her partners at PRMA do, too. She says it is simple and quick.
What About a 3-D Tattoo to Create a Nipple Reconstruction?
Dr. Carpenter points out that the C-V flap is just the nipple. The areola is then tattooed on at a later time after proper healing. She also offers her patients another way to recreate the nipple areola for those who do not want nipple reconstruction. A 3D nipple tattoo done by a qualified, skill tattoo artist can create the illusion of the nipple/areola complex without nipple reconstruction. Some women prefer this since they don’t want the projection or the extra procedure.
I take the opportunity to give a shout out to the Alliance of Medical Tattooing. It is an honor to be on their advisory board and to be able to share with patients trained, certified medical tattoo artists listed on their website. Patients carefully choose their reconstructive surgeon. It is important to choose a medical tattoo artist to do a 3D nipple tattoo after breast reconstruction surgery.
Recovery and Bandaging for Nipple Reconstruction
At PRMA they use a piece of gauze and cut a hole in the middle and tape it around the newly created nipple. Most surgeons ask that you don’t put too much pressure on it. Something like a light camisole works to help keep the bandage on but not “squishing” the new nipple. They always inject and numb their patients but often there is minimal pain reported. At PRMA they routinely perform nerve reconstruction to restore sensation but at this point in the reconstruction many patients still don’t have sensation because it takes sensation a long time to “creep in” from the periphery.
A patient’s skin starts healing within twenty-four to forty-eight hours. Complete healing occurs in a couple of weeks after the nipple reconstruction procedure. Dr. Carpenter points out that the discomfort is very minimal compared to other revision procedures done to finalize the reconstruction process. She also tells us over time the nipple will flatten out a bit just as a natural nipple does over time.
Do Patients Come to PRMA for Nipple Reconstruction who Have not had Breast Reconstruction?
Yes. Dr. Carpenter treated a patient who had a different disease process other than breast cancer. She will be removing the patient’s nipple and recreating a new one. There are people who will need nipple reconstruction without breast reconstruction.
Dr. Carpenter summarizes her thoughts at the end of the podcast. Nipple reconstruction is something people don’t think about. They hear their diagnosis and are thinking about breasts. They are not necessarily thinking about the nipples or the thought that their nipples might be removed isn’t something that even crosses their mind, even though it might be on my mind or their breast surgeon’s mind.
I think that people should be encouraged to ask more questions. Especially if they are a candidate for preserving their nipples or not preserving their nipples. Questions are always great! I love questions, it means you’re thinking about it! You’re trying to get as much data as you want or as you need in order to make your decision.
You can listen to the entirety of the podcast here.